One third of American hemodialysis patients receive inadequate amounts of dialysis. This contributes to dialysis patient mortality rates that are the highest in the industrialized world at 23%/year. Inadequate dialysis probably also contributes to high costs, including an average of two hospitalizations annually per patient and total Medicare expenditures of $10 billion/year. Their prior work identified four factors that are likely to be the most important barriers to adequate dialysis (patient noncompliance, low dialysis prescription, catheter use, and clotting) and documented inadequate patient-provider communication and patient understanding of dialysis adequacy. This proposed community-based randomized controlled trial extends their prior work by targeting these specific barriers to adequate dialysis with a tailored feedback and communication intervention. Thirty dialysis facilities in northeast Ohio will be randomly assigned to intervention and control groups, with 120 patients receiving inadequate dialysis enrolled from 15 intervention and control groups, with 120 patients receiving inadequate dialysis enrolled from 15 intervention facilities and 120 from 15 control facilities. Baseline evaluation will include measures of dialysis delivery, specific barriers, and inpatient expenditures for a six month retrospective interval. Intervention patients and their physicians and nurses will receive tailored feedback on dialysis adequacy and on overcoming patient-specific barriers. They will then meet to formulate a care plan addressing these barriers. Bimonthly progress reports will also be provided to intervention patients and providers over a six month follow-up period. Major analyses will compare changes in dialysis adequacy and hospitalization-related costs in intervention vs. control patients with adjustment for nesting of patients within facilities. The proposed project will test a novel intervention that targets patients and providers as they together make decisions about dialysis treatment. Overcoming specific barriers may lead not only to improved dialysis adequacy but also to better patient survival and decreased health care costs.